Professor Paulette Van Vliet

A call to arms

Across the world, 15 million people will experience stroke annually. Of these, 77 per cent will have arm issues and only half will regain arm functionality. Professor Paulette Van Vliet's focus on this portion of the body, stretching from the shoulder to fingertips, is imperative to the recovery
of people who have experienced a stroke.

It was during her time as a young physiotherapist in Lidcombe Hospital, Sydney, that Paulette's interest in the treatment of the upper limb was piqued.

"As therapists we had to fight to be allowed to treat the arm for as long as we wanted," Paulette explains.

"The emphasis was always on getting the patient up and walking, so that they could go home."

But when patients returned home, despite some outpatient therapy, many would never regain total use of their arm.

"For a therapist who knew that their arm could be better, I found that very short-sighted and felt I had to fight for peoples' arm recovery."

Paulette's research vision for stroke rehabilitation of the upper limb has three key goals: getting more recovery for more people; targeting treatments to people with particular deficits; and empowering patients to practice alone. The three tiers combine, like intertwining fingers in a healthy patient,
towards the ultimate objective of reaching a person's potential.

The global significance of Paulette's work is exemplified by her experiences in researching abroad and six current international collaborative projects. Completing her Masters at Loughborough University in the United Kingdom and gaining her Philosophy Doctorate in 1998 at the University of Nottingham,
Paulette developed her techniques of motion analysis in movement and kinematics, focusing on the detailed movement deficits in those who have experienced stroke, compared to healthy people.

"Movement kinematics are like a window into how the brain controls the movement, so knowing these deficits is a prerequisite before you can know how to retrain movement," she states.

By contrasting the two groups, Paulette and her research team can identify changes needed to improve movements requested by therapists of stroke rehabilitation patients.

After rising through the ranks in British universities, Paulette returned to Australia in 2010 where she commenced work with the University of Newcastle and promptly secured an Australian Research Council Future Fellowship. Her work, much of it taking place in the motion lab of the Hunter Medical Research
Institute (HMRI), has culminated in the innovation of the Arm Movement Measure Device (the ArMM device).

This device will enable physiotherapists to provide immediate feedback about kinematics. Fitted with motion sensors at points between the wrist and hand, the ArMM device allows the recording of acceleration, velocity and hand position in reach-to-grasp movements to the exact millisecond. Therapists
can then draw attention to items of concern and patients can check how they are tracking after each attempt, by using the feedback from ArMM to improve upon their deficit.

"The device will reinforce the right movements and help the synaptic connections in the brain that will create the right neural pathways," Paulette clarifies.

A multidisciplinary project, the ArMM device pushes scientific boundaries and involves collaboration with Paulette's academic colleagues in electrical engineering, mathematics, commercial innovation and a number of other talented staff. The project has also provided opportunities for postgraduate students
in developing and promoting the electronic device.

The artful yet simple ArMM device, funded by a National Health and Medical Research Council Development Grant, most notably fits into Paulette's purpose of empowering patients, as it will also allow self-directed therapy in the home.

"Patients will be able to use it on their own, dramatically increasing the amount of practice available to them," Paulette says.

The implementation of this device in the patient's living space would allow for therapists to bridge gaps in motion repetitions. Current literature in the field has determined hundreds of repetitions are required for the brain to recover, following the catastrophic effects of a stroke. The recommended
target is around 300 repetitions per rehabilitation session, however these numbers are difficult to reach during one-on-one therapy. Present studies of outpatient therapy cite an average of 12 repetitions of purposeful movements per session – well below the recommended target.

The ArMM is only one way to meet the required repetitions to enable stroke survivors to recuperate to their potential. As Paulette sees it, 300 reach-to-grasp repetitions could be achieved in a variety of ways such as: 100 in sessions with a therapist; completing 100 at home exercises; and a further
hundred using ArMM to allow for the more permanent learning of tasks.

The benefits of the ArMM device are obvious, particularly given present healthcare resources allocated to stroke rehabilitation. Following the average term of six weeks hospitalisation for a stroke, depending on medical opinion, there are four options for someone discharged following the event:

no further treatment as they are determined to be recovered;

outpatient therapy twice a week which ceases after several months;

minimal Government-funded therapy in the home; or

private therapy, which can prove expensive and hard to find.

Regardless of the path taken, this vital healthcare typically ceases at six months. Such a system proves frustrating to Paulette.

"People can keep improving for years… if they're given the right instructions and exercises."

ArMM will be particularly beneficial for people in remote communities in both developed and developing nations where physiotherapy services are lacking.

"As long as they have the device and some remote communication with a therapist, such as via the internet, they'd be able to work on their own," Paulette affirms.

The dedication Paulette has put into the ArMM device is mirrored in a string of other research projects with her team. These include a combined sensory and motor training approach to ensure synchronous activation of brain networks to improve performance. Also, her research has shown that varying reach-to-grasp
practice with different distances, speeds and directions, allows the brain to practice planning movements for different contexts. Task-specific therapy with aerobic training on a bike-like apparatus is also being investigated to determine the role of exercise in brain function ahead of arm training.
The definition of brain lesions to determine motion deficits through functional magnetic resonance imaging (fMRI) is also being developed. All of these projects are significant, as the same treatments do not benefit all people, and there is insufficient insight into brain areas affected by stroke.

Paulette and her colleagues work has recently been validated by a Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery grant. These have been awarded to 10 chief investigators across the country, four being University of Newcastle academics. It focuses on five key research streams,
four of which Paulette's work can be classified as belonging to: neuroimaging, clinical trials, implementation research and data linkage, all areas to improve the quality of life of stroke patients.

In Australia, 50,000 people will experience a stroke each year. A further 420,000 live with the effects of stroke, with this number expected to rise to 700,000 people by 2032. This medical condition costs the nation $5 billion annually in hospital, rehabilitation and further care. Stroke is increasingly
impacting on younger people, and with the retirement age pushed further back, people's arm recovery is imperative to the productivity of the nation.

"If we can improve arm function it will reduce a lot of these costs," Paulette advises.

Improving arm function research through the next generation of researchers is also on the Paulette's agenda. She is deeply passionate about guiding young physiotherapists in stroke rehabilitation researchers and has taught 70 undergraduate courses over her career both on British and Australian soil.
She currently supervises a team of six international and two Australian PhD candidates working closely alongside her at HMRI.

Career Summary

Biography

Professor van Vliet is an ARC Future Fellow at the University of Newcastle. Research interests are recovery of upper limb motor control after stroke, evaluation/development of physiotherapy intervention for stroke patients, and motor skill acquisition. Current research focuses on the temporal coordination of reach-to-grasp in patients with stroke.

Research ExpertiseRecovery of upper limb motor control after stroke Evaluation and development of physiotherapy intervention for people with stroke Motor skill acquisition following stroke

CollaborationsProfessor van Vliet works within the PRC for Brain and Mental Health and collaborates with researchers at the Universities of Birmingham, University of Norwich, University of Western England and Glasgow Caledonian University.

Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-an... [more]

Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-analysis of randomized controlled trials to collate the available evidence in adults with residual motor impairments as a result of stroke. The primary outcome was change in motor function or impairment as a result of transcranial direct current stimulation, using any reported electrode montage, with or without adjunct physical therapy. The search yielded 15 relevant studies comprising 315 subjects. Compared with sham, cortical stimulation did not produce statistically significant improvements in motor performance when measured immediately after the intervention (anodal stimulation: facilitation of the affected cortex: standardized mean difference=0Â·05, P=0Â·71; cathodal stimulation: inhibition of the nonaffected cortex: standardized mean difference=0Â·39, P=0Â·08; bihemispheric stimulation: standardized mean difference=0Â·24, P=0Â·39). When the data were analyzed according to stroke characteristics, statistically significant improvements were evident for those with chronic stroke (standardized mean difference=0Â·45, P=0Â·01) and subjects with mild-to-moderate stroke impairments (standardized mean difference=0Â·37, P=0Â·02). Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to patients with stroke. Given the range of stimulation variables and heterogeneous nature of stroke, this modality is still experimental and further research is required to determine its clinical merit in stroke rehabilitation.

Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A syste... [more]

Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke. Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 Â± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths.

Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-an... [more]

Transcranial direct current stimulation has been gaining increasing interest as a potential therapeutic treatment in stroke recovery. We performed a systematic review with meta-analysis of randomized controlled trials to collate the available evidence in adults with residual motor impairments as a result of stroke. The primary outcome was change in motor function or impairment as a result of transcranial direct current stimulation, using any reported electrode montage, with or without adjunct physical therapy. The search yielded 15 relevant studies comprising 315 subjects. Compared with sham, cortical stimulation did not produce statistically significant improvements in motor performance when measured immediately after the intervention (anodal stimulation: facilitation of the affected cortex: standardized mean difference=0Â·05, P=0Â·71; cathodal stimulation: inhibition of the nonaffected cortex: standardized mean difference=0Â·39, P=0Â·08; bihemispheric stimulation: standardized mean difference=0Â·24, P=0Â·39). When the data were analyzed according to stroke characteristics, statistically significant improvements were evident for those with chronic stroke (standardized mean difference=0Â·45, P=0Â·01) and subjects with mild-to-moderate stroke impairments (standardized mean difference=0Â·37, P=0Â·02). Transcranial direct current stimulation is likely to be effective in enhancing motor performance in the short term when applied selectively to patients with stroke. Given the range of stimulation variables and heterogeneous nature of stroke, this modality is still experimental and further research is required to determine its clinical merit in stroke rehabilitation.

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can... [more]

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes. Studies in healthy individuals and those with neurological dysfunction provide examples of strategies that may also be used to enhance neuroplasticity during the rehabilitation of individuals with musculoskeletal dysfunction, improving the effectiveness of interventions. In this paper, the evidence for neuroplastic changes in patients with musculoskeletal conditions is discussed. The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction. This may lead to greater integration of strategies to enhance neuroplasticity in patients treated in musculoskeletal physiotherapy practice.

An Investigation of Neuroplasticity Underlying the Effects of Combining Arm Task Specific Training and Aerobic Exercise after StrokePhysiotherapy, Faculty of Health and MedicinePrincipal Supervisor

2014

Aerobic Exercise to Increase Efficacy of Task-Specific Training for the Upper Limb after Stroke: A Feasibility StudyPhysiotherapy, Faculty of Health and MedicinePrincipal Supervisor

2014

An Investigation of Neuroplasticity Underlying the Effects of Combining Arm Task Specific Training and Aerobic Exercise After StrokePhysiotherapy, Faculty of Health and MedicinePrincipal Supervisor

2013

Establishing an fMRI Biomarker for Recovery of Arm Coordination after Stroke. Towards Identification of Lesions in the Brain Post Stroke. A Mapping and Image Analytic ParadigmPhysiotherapy, Faculty of Health and MedicineCo-Supervisor

2012

Prevention of Stroke Through Improving FitnessPhysiotherapy, Faculty of Health and MedicinePrincipal Supervisor

News

Congratulations to Professor Paulette Van Vliet from the School of
Health Sciences on her successful application for an NHMRC Development
Grant for the continued development of the Arm Movement Measurement
(ArMM) device.